State Inspection Deficiencies

Findings in these inspections do not present a complete picture of the quality of care provided.
Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.
We suggest you use our Nursing Home Checklist to help evaluate the nursing homes you plan to visit.

Deficiency DescriptionFailed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

Scope: Isolated + Harm:
Immediate

Severity:

5

Date of Correction 3/10/2017

Deficiency DescriptionFailed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Have a program that investigates, controls and keeps infection from spreading.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .

Scope: Isolated + Harm:
Immediate

Severity:

5

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility

Scope: Pattern + Harm:
Actual

Severity:

5

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Deficiency DescriptionFailed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

Scope: Isolated + Harm:
Minimal

Severity:

3

Deficiency DescriptionFailed To: Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion, unless it is unavoidable due to resident’s clinical condition.

Scope: Isolated + Harm:
Actual

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Deficiency DescriptionFailed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 5/3/2017

Deficiency DescriptionFailed To: Permit residents to remain in the facility and not be transferred or discharged without adequate reason.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 3/10/2017

Deficiency DescriptionFailed To: Provide timely notification to the resident before transfer or discharge.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 3/10/2017

Deficiency DescriptionFailed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Provide medically-related social services to help each resident achieve the highest possible quality of life.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 4/6/2017

Deficiency DescriptionFailed To: Provide necessary care and services to maintain or improve the highest well being of each resident .

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 5/3/2017

Deficiency DescriptionFailed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Deficiency DescriptionFailed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 12/7/2015

Deficiency DescriptionFailed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.

Deficiency DescriptionFailed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being.

Scope: Pattern + Harm:
Minimal

Severity:

4

Date of Correction 12/12/2016

Deficiency DescriptionFailed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

Scope: Isolated + Harm:
Immediate

Severity:

5

Date of Correction 12/12/2016

Deficiency DescriptionFailed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .

Scope: Widespread + Harm:
Minimal

Severity:

5

Date of Correction 12/12/2016

Deficiency DescriptionFailed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility

Deficiency DescriptionFailed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Scope: Isolated + Harm:
Actual

Severity:

4

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficiency DescriptionFailed To: Provide necessary care and services to maintain or improve the highest well being of each resident .

Scope: Isolated + Harm:
Immediate

Severity:

5

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Scope: Isolated + Harm:
Actual

Severity:

4

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being.

Scope: Isolated + Harm:
Actual

Severity:

4

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Have a program that investigates, controls and keeps infection from spreading.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .

Scope: Widespread + Harm:
Minimal

Severity:

5

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility

Scope: Widespread + Harm:
Minimal

Severity:

5

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.

Scope: Widespread + Harm:
Minimal

Severity:

5

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Scope: Widespread + Harm:
Minimal

Severity:

5

Date of Correction 8/26/2016

Deficiency DescriptionFailed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

3/29/2016 Inspection

Deficiency DescriptionFailed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 4/29/2016

Deficiency DescriptionFailed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 4/29/2016

Deficiency DescriptionFailed To: Provide medically-related social services to help each resident achieve the highest possible quality of life.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 4/29/2016

Deficiency DescriptionFailed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

1/27/2015 Inspection

Deficiency DescriptionFailed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Scope: Isolated + Harm:
Minimal

Severity:

3

Date of Correction 3/25/2015

About The Staff

(Higher numbers are better)

Hours Per Day Per Resident

This Facility

County Avg

State Avg

Number of Residents

126

81

74

Registered Nurses

0.68 hrs

1.14 hrs

1.07 hrs

Licensed Practical / Vocational Nurses

0.87 hrs

0.65 hrs

0.66 hrs

Certified Nursing Assistants

2.47 hrs

2.60 hrs

2.50 hrs

Total Staff Hours

4.03 hrs

4.40 hrs

4.23 hrs

About the Residents

(Read each measure closely)

Percent of Residents

This Facility

County Avg

State Avg

high risk long-stay residents with pressure ulcers

2%

4%

4%

long-stay residents assessed and appropriately given the pneumococcal vaccine

74%

95%

94%

long-stay residents assessed and appropriately given the seasonal influenza vaccine

95%

95%

95%

long-stay residents experiencing one or more falls with major injury

1%

2%

2%

long-stay residents who have depressive symptoms

1%

10%

9%

long-stay residents who lose too much weight

5%

6%

6%

long-stay residents who received an antianxiety or hypnotic medication

8%

12%

15%

long-stay residents who received an antipsychotic medication

16%

13%

15%

long-stay residents who self-report moderate to severe pain

3%

5%

7%

long-stay residents who were physically restrained

0%

1%

0%

long-stay residents whose ability to move independently worsened

14%

16%

17%

long-stay residents whose need for help with daily activities has increased

12%

12%

13%

long-stay residents with a catheter inserted and left in their bladder

1%

2%

2%

long-stay residents with a urinary tract infection

1%

3%

3%

low risk long-stay residents who lose control of their bowels or bladder

33%

55%

52%

short-stay residents assessed and appropriately given the pneumococcal vaccine

46%

88%

85%

short-stay residents who had an outpatient emergency department visit

11%

10%

11%

short-stay residents who made improvements in function

35%

67%

70%

short-stay residents who newly received an antipsychotic medication

0%

0%

1%

short-stay residents who self-report moderate to severe pain

23%

13%

16%

short-stay residents who were assessed and appropriately given the seasonal influenza vaccine

69%

87%

84%

short-stay residents who were rehospitalized after a nursing home admission

27%

16%

16%

short-stay residents who were successfully discharged to the community

48%

61%

60%

short-stay residents with pressure ulcers that are new or worsened

0%

0%

0%

Deficiency Ratings

Our nursing home inspector tools compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity = Scope + Level of Harm.

Then, we add up all of the severity ratings to get our final Deficiency Rating.

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state in which they operate and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Be sure to examine the full descriptions provided under the Detailed Report. Some deficiencies may be more critical than others based upon the type. For example, administrative deficiencies may be less important to you than mistreatment or quality of care deficiencies.

State inspection details provide useful information that can help you compare nursing homes in your area and decide what types of questions you may want to ask when you visit the nursing home.

Note: Every attempt is made to assure that the most recent survey results are available on this website. Surveys are generally conducted every 9-15 months, however, all homes are not inspected each year.

About The Staff

This area shows the average number of staff hours worked each day by RNs, LPNs/LVNs and CNAs divided by the number of residents.

This is a good measure of the trained medical staff available, on average, for comparison purposes.
The number of hours worked per patient is a relative statistic for comparison between different homes as well as County and State averages.

Although more hours per patient should mean better care, there are no measures for the individual care received by any given patient and the quality of care provided may be more a factor of training and dedication than the number of hours worked.

Each nursing home reports the staffing hours for a two-week period prior to the time of the state inspection.

Hours per resident per day is the average amount of hours worked divided by the total number of residents. It does not necessarily show the number of nursing staff present at any given time, or reflect the amount of care given to any one resident.

The Centers for Medicare and Medicaid Services requires nursing homes to have enough staff to give adequate care to all residents. There is no current federal standard for optimal nursing staff levels, although federal law requires all nursing homes to provide enough staff to adequately care for residents. The nursing home must have at least one RN for at least 8 straight hours a day, 7 days a week and either an RN or LPN/LVN on duty 24 hours per day. Certain states may have additional staffing requirements.

These numbers are for reference only. Some nursing homes might require more nursing staff due to the conditions of their residents and other factors such as whether the nursing home has special care units.

Reference: The Official U.S. Government Site for People with Medicare

Level of Harm Definitions

Potential for Minimal Harm (1 Point)
This deficiency has the potential for causing no more than a minor negative impact on the resident.

Example:The nursing home's statement of deficiencies was not posted, nor was there any sign indicating where it was. The nursing home keeps the statement of deficiencies in the business office and shows it to residents upon request.

Minimal Harm or Potential for Actual Harm (2 Points)
This deficiency results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Example:Staff were observed not washing hands properly between resident treatments. There is no evidence of the transmission of infection between residents by staff.

Example:A resident was "active and vocal" on admission to the nursing home. The nursing home restrained the resident 6 months ago, despite the lack of medical symptoms for doing so. The resident is now withdrawn, does not attend activities, and is "down in the dumps."

Immediate Jeopardy (4 Points)
This deficiency places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the nursing home. Immediate corrective action is necessary when this deficiency is identified.

Example:A resident with dementia was found outside during an inspection, heading toward a nearby highway. The nursing home had no working system in place to monitor residents with dementia.

Reference: The Official U.S. Government Site for People with Medicare

Scope Definitions

Isolated (1 Point)
This deficiency potentially or actually affects a few residents.

Example:60 of 70 residents in the nursing home are incontinent. The nursing home failed to provide adequate care of services to restore or improve bladder function in 2 of these residents.

Example:60 of 70 residents in the nursing home are incontinent. The nursing home failed to provide adequate care of services to restore or improve bladder function in half of these residents.

Reference: The Official U.S. Government Site for People with Medicare

About the Residents

This information will allow comparisons to be made among nursing homes about the proportion of residents with a particular condition. In addition, it can be used to help you decide what type of questions you may want to ask when you visit the nursing home.

This data alone should not be used to make a decision. It is important to use these numbers only as a starting point. High or low percentages may be the result of factors other than quality. Percentages for a particular measure may vary widely among nursing homes.

You should plan to visit the nursing home before making a decision. In addition, you should use this information in conjunction with the state inspection results found in the "About State Inspection Deficiencies" section of this report.

It is important to note that these characteristics are reported by the nursing home and are not audited.

Nkc Broadway Kidney Center

Nkc Elliott Bay Kidney Center

About The Home

This information is collected through the inspection process and is reviewed by nursing home inspectors.

Accepts Medicare
Medicare pays for some nursing home care in specific situations and for no more than 100 days for each benefit period. A benefit period begins the day you go to a skilled nursing facility. The benefit period ends when you have not received skilled nursing care for 60 days in a row.

Accepts Medicaid
Medicaid pays for long term care for people with low incomes and resources. Check out with your State Medicaid Agency for the income levels in your State. If a nursing home does not participate in the Medicaid program and does not accept Medicaid patients, and the resident runs out of other funds/coverage, the resident will have to move to another nursing home if he/she wants to be on Medicaid.

Type of Ownership
Nursing homes can be run by private for-profit corporations, non-profit corporations, religious affiliated organizations or government entities. Quality can vary in nursing homes within each of the different types of ownership. Each nursing home needs to be judged on its own merits.

Located within a Hospital
The nursing home is affiliated with a hospital. Often if a home is located within a hospital setting, it usually provides short-term rehab only.

Resident and Family Councils
Resident and family councils can facilitate communications with staff. The law requires nursing homes to allow councils to be set up by residents and families. If a nursing home does not have a resident and family council, ask the Administrator why. Ask to talk with council presidents to get a sense of how the nursing home has acted on their concerns.

Beds
This measure represents the total number of Medicare/Medicaid Certified Beds in the nursing home. Some nursing homes can have a combination of Medicare, Medicaid, and/or private pay beds. Please check with the nursing home to find out what types of beds are available.

Residents
This number tells you how many residents in Medicare/Medicaid Certified Beds were living in the nursing home at the time of the inspection.